# Adolescent Medicine: The Med-Peds Sweet Spot

## Introduction

Adolescents (ages 10-24) occupy the unique intersection of pediatric and adult medicine. Med-peds physicians are ideally positioned to address the **complex physical, psychological, and social changes** of this population. Adolescent medicine encompasses puberty, risk-taking behaviors, mental health, reproductive health, and the transition to adult care.

## The HEEADSSS Assessment

| Domain | Letter | Key Questions | Risk Indicator |
|--------|--------|--------------|---------------|
| Home | H | Who lives at home? Feel safe? Conflict? | Instability, abuse, homelessness |
| Education/Employment | E | Grades? Suspensions? Future plans? | Declining performance, absenteeism |
| Eating | E | Body image? Dieting? Purging? | Disordered eating behaviors, weight changes |
| Activities | A | Friends? Sports? Screen time? | Isolation, excessive screen use |
| Drugs | D | Tobacco? Alcohol? Marijuana? Vaping? | Frequent use, use alone, functional impairment |
| Sexuality | S | Orientation? Activity? Contraception? STIs? | Unprotected sex, coercion, early onset |
| Suicide/Depression | S | Mood? Self-harm? Suicidal ideation? | PHQ-A positive, prior attempts, plan |
| Safety | S | Seatbelts? Helmets? Guns? Violence? Bullying? | Firearms access, DV, cyberbullying |

The **HEEADSSS** psychosocial interview is the foundation of the adolescent visit:

**H**ome: Living situation, family relationships, safety. **E**ducation/Employment: School performance, future plans. **E**ating: Diet, body image, disordered eating behaviors. **A**ctivities: Hobbies, exercise, screen time, peer relationships. **D**rugs: Tobacco, alcohol, marijuana, other substances. **S**exuality: Sexual orientation, gender identity, sexual activity, contraception. **S**uicide/Depression: Mood, self-harm, suicidal ideation. **S**afety: Seatbelts, helmets, violence exposure, bullying, firearms.

### Confidentiality
Explain confidentiality and its limits at the start of each visit. Spend time alone with the adolescent (without parent) Know your **state-specific minor consent laws** for reproductive health, mental health, and substance use treatment.

## Puberty and Growth

### Normal Pubertal Development
**Girls**: Thelarche (breast budding, Tanner stage 2) typically age 8-13; menarche approximately 2-2.5 years after thelarche. **Boys**: Testicular enlargement (>4 mL) typically age 9-14. Growth spurt: Girls peak at Tanner 2-3; boys peak at Tanner 3-4.

### Pubertal Concerns
**Precocious puberty**: Secondary sexual characteristics before age 8 (girls) or 9 (boys) **Delayed puberty**: No breast development by age 13 (girls) or no testicular enlargement by age 14 (boys) Evaluation includes bone age, LH, FSH, estradiol/testosterone, and pelvic/testicular ultrasound.

![Tanner staging chart for male and female pubertal development](images/tanner-staging.jpg)

## Reproductive and Sexual Health

### Contraception
Provide comprehensive, nonjudgmental counseling. **LARC methods** (IUDs, implants) are first-line for adolescents per AAP and ACOG. Emergency contraception: Discuss availability and indications. STI screening: Chlamydia and gonorrhea annually for sexually active females under 25.

### Gender-Affirming Care
Use correct names and pronouns; Understand the spectrum of gender identity; Puberty blockers (GnRH agonists) may be considered for gender dysphoria; Multidisciplinary approach: mental health, endocrinology, primary care.

## Mental Health

### Depression and Anxiety
Screen with **PHQ-A** (Patient Health Questionnaire for Adolescents) at annual visits. Depression prevalence: ~13% of adolescents; higher in LGBTQ+ youth. First-line treatment: **CBT** and/or **fluoxetine** (FDA-approved for ages 8+) Monitor closely for suicidality, especially in first weeks of SSRI initiation.

### Eating Disorders
Anorexia nervosa, bulimia nervosa, avoidant/restrictive food intake disorder (ARFID) Screen with questions about body image, weight control behaviors, menstrual irregularity. Medical complications: bradycardia, electrolyte abnormalities, bone density loss. Multidisciplinary management with therapy, nutrition, and medical monitoring.

## Substance Use

Screening: **CRAFFT** tool validated for adolescents; Vaping/e-cigarettes: Nicotine exposure, lung injury risk; Marijuana: Impacts on developing brain, particularly executive function; Brief motivational interviewing is effective for mild-moderate use; Refer for specialized treatment when indicated.

![Infographic showing CRAFFT screening questions](images/crafft-screening.jpg)

## Common Medical Concerns

### Acne
Mild: Topical retinoids, benzoyl peroxide. Moderate: Add topical or oral antibiotics. Severe/Nodulocystic: Isotretinoin (requires iPLEDGE program; pregnancy prevention mandatory)

### Sports Medicine
Preparticipation physical evaluation. Concussion recognition and return-to-play protocols. Overuse injuries and relative energy deficiency in sport (RED-S)

### Chronic Disease in Adolescence
Type 1 diabetes self-management. Asthma adherence. IBD, epilepsy, and other chronic conditions requiring transition planning.

## Transition to Adult Care

Begin transition planning at age 12-14; Use tools like **Got Transition** Six Core Elements framework; Assess readiness for self-management; Transfer medical summary, emergency plan, and specialist contacts.

![Flowchart for transition from pediatric to adult care](images/transition-care-flowchart.jpg)

## Clinical Pearls

Always see adolescents alone for part of the visit; this is where the real conversation happens. LARC methods are safe and highly effective in adolescents; dispel myths about IUD use in nulliparous patients. The CRAFFT tool is a quick, validated substance use screen that takes under 2 minutes. Eating disorders have the highest mortality of any psychiatric illness; early identification is critical. Med-peds physicians bridge the gap between pediatric and adult systems, making them ideal adolescent medicine providers.

## References

1. Goldenring JM, Rosen DS. Getting into adolescent heads: An essential update. *Contemp Pediatr*. 2004;21(1):64-90.
2. Committee on Adolescence, American Academy of Pediatrics. Contraception for adolescents. *Pediatrics*. 2014;134(4):e1244-e1256.
3. Knight JR, Sherritt L, Shrier LA, et al. Validity of the CRAFFT substance abuse screening test among adolescent clinic patients. *Arch Pediatr Adolesc Med*. 2002;156(6):607-614.
4. White PH, Cooley WC. Supporting the health care transition from adolescence to adulthood in the medical home. *Pediatrics*. 2018;142(5):e20182587.